An Emergency Medical Liaison System for Acute Stroke Care in Japan: An example of the Tokyo Metropolitan Area
|
|
- Linette Willis
- 6 years ago
- Views:
Transcription
1 Research and Reviews An Emergency Medical Liaison System for Acute Stroke Care in Japan: An example of the Tokyo Metropolitan Area JMAJ 54(1): 3 9, 2011 Tohru ARUGA* 1 Abstract In Japan, Fire Service Act, which was partially amended in 2009, stipulates that each prefectural council is required to create a list of medical institutions (hospitals) by pathophysiological conditions of patients transported by ambulance. The Act also demands that emergency crews and hospitals share the patient s information and that the fire service and hospitals establish policies to deal with the cases when the receiving hospitals cannot be decided promptly. In Tokyo, Committee for Emergency Care Standards (of Tokyo Medical Control Council) and Tokyo Stroke Care Liaison Council (of Tokyo Emergency Medical Council) exchanged information closely and established a liaison system between the emergency service and hospitals. Specifically, lists of hospitals that can deal with stroke and those that cannot were prepared based on the information provided by hospitals. Also, it was decided that the emergency service is to transport patients using the Cincinnati prehospital stroke scale. There are over 100 hospitals listed as stroke ready. Assuming all of them are to handle 30,000 patients per year evenly, the rate per day is 0.8 patient/hospital/day. In the future, an important issue to address would be to promote qualitative improvement of this liaison system through crosschecking the assessments of emergency crews and the definitive diagnoses of the transported patients. 500 km Tokyo, Japan Population: 13.1 million (est.) Area: 2,188 km 2 [Source: Tokyo Metropolitan Government (as of Nov 2010).] Key words Stroke, Medical Control Council, Partial amendment of Fire Service Act Introduction In Japan, the recent partial amendment of Fire Service Act in 2009 stipulates that prefectural governments have to set up councils, which discusses rules for the fire service to transport emergency patients and for medical institutions (hospitals) to accept them. This establishment of councils can be understood as an extension of the previously held discussions on expanding the conventional medical control (MC) council s functions and the enhancement of their positioning. 1 Namely, in addition to the ordinary activities of securing and improving the quality of treatment techniques provided by emergency crews, the responsibilities of MC councils are to be expanded to include recommending the appropriate way of transport (including selecting the *1 Department of Emergency and Critical Care Medicine, Showa University School of Medicine, Tokyo, Japan (aruga@med.showa-u.ac.jp). This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol.138, No.7, 2009, pages ). 3
2 Aruga T Independent Efforts by Tokyo Metropolitan Government Tokyo Stroke Care Liaison Promotion Project Tokyo Emergency Medical Council Tokyo Stroke Care Liaison Council Secretariat Medical Policy Section* Partial Amendments of Fire Service Act Tokyo Medical Control Council Secretariat Tokyo Fire Department Members 6 Fire Departments in Tokyo, Medical Policy Section,* Tokyo Medical Association, Acute Medicine Specialists, ets. Committee for Education of Emergency Crews Committee for Post-hoc Verification Acute Stroke Care Planning in Tokyo (Information exchange & share) Committee for Emergency Care Standards Committee for Mecical Instructors * Medical Policy Section, Medical Policy Division, Tokyo Metropolitan Government. Fig. 1 Acute stroke care planning in Tokyo, Japan Practice standards Prefectural governments should develop and publish the following: 1. A list of medical institutions (hospitals) that provide appropriate medical care based on the condition of the patient. 2. Criteria for the fire service to confirm the condition of the patient and to select a suitable hospital from the list stated in the Item 1 above. 3. Criteria for the fire service to inform the hospital of the patient's condition. 4. Criteria for reaching a consensus between the fire service and hospitals to determine which hospital should accept the patient when the receiving hospital cannot be decided promptly. Various support, including provision of information Minister of Public Management, Home Affairs, Posts and Telecommunications Minister of Health, Labour and Welfare Must be based on medical findings Must be consistent with healthcare planning Fire service Medical institutions (hospitals) Hearing of opinions when formulating criteria Council Comply with the practice standards when transporting patients. Strive to comply with the practice criteria when accepting patients. Fig. 2 Explanation of the partial amendment of Fire Service Act of Japan the site of the emergency. Transporting a patient to an appropriate hospital, which comes as the next step, is also a critical issue. Therefore, in such regard, the recent partial amendment of Fire Service Act deserves high appraisal. In some prefectures, an MC council is estabreceiving hospital most suitable for a patient) and making suggestions for the development and improvement of such acceptance systems. The reason that MC councils take part in the care to be provided by emergency crews is to facilitate an appropriate response to patients at 4
3 AN EMERGENCY MEDICAL LIAISON SYSTEM FOR ACUTE STROKE CARE IN JAPAN: AN EXAMPLE OF THE TOKYO METROPOLITAN AREA Table 1 Accreditation criteria of acute stroke-ready hospitals in Tokyo, Japan: Towards developing a medical liaison system for stroke patients for the entire Tokyo area 1. Concept behind the formulation of the emergency transport system for stroke patients in the entire Tokyo Stroke cases can be classified as cerebral infarction, cerebral hemorrhage, or subarachnoid hemorrhage, and effective treatment can vary according to the pathologic condition and the time course, such as intravenous alteplase (t-pa) therapy for the hyper-acute phase of cerebral infarction. Therefore, it is important for every stroke patient to be transported to a hospital as early as possible and to receive appropriate treatment in order to minimize potential physical impediments. 2. Criteria for accreditation of acute stroke-ready hospitals A hospital that satisfies the following requirements is designated as the acute stroke-ready hospital in the Tokyo Medical Liaison System for Stroke. Accreditation criteria of acute stroke-ready hospitals in Tokyo 1 The institution has physicians and paramedical staff who have sufficient knowledge and experience to deal with acute stroke. 2 The hospital has an in-hospital system in place that allows prompt implementation of imaging tests, such as brain CT and MRI and necessary laboratory examinations. 3 The hospital has beds/wards specifically designated for acute stroke patients and has full-time physical therapist(s) and/or occupational therapist(s) who can provide acute-phase rehabilitation. 4 The hospital can provide prompt consultation by a neurosurgeon for a patient who needs neurosurgery. (If there is no neurosurgeon on duty, the patient can be promptly referred to a neurosurgeon on-call or transferred to a cooperating hospital as necessary for consultation.) 5 To ensure the quality of medical care for stroke patients, the hospital must have at least 1 physician who can prove that he/she has participated in the t-pa therapy course approved by Japan Stroke Society. Intravenous t-pa has to be administered under the guidance of the said physician. 6 The hospital is equipped to provide the intravenous t-pa therapy to the applicable patient within 1 hour after the arrival. 7 Whenever the t-pa therapy is performed, the institution is able to provide at least 36 hours of continuous observation necessary to promptly deal with any adverse effects for the purpose of patient management. Required (Group B) Required for t-pa ready hospitals for patients with hyper-acute cerebral infarction (Group A) lished in each secondary medical district, whereas some already have an emergency medical council that is involved in healthcare planning. Thus, how an MC council will develop in each community remains to be seen. In Tokyo, acute stroke care is planned by Tokyo Medical Control Council and Tokyo Emergency Medical Council in large (Fig. 1). In any case, at least from the viewpoint of MC councils, the recent partial amendment of Fire Service Act has played an important role in defining the legal and administrative positions of MC councils and in promoting the discussion on the subject of emergency medical liaison for acute stroke care at the community level. Methodology for Formulating an Emergency Medical Liaison System for Acute Stroke Care Figure 2 shows the excerpt from the reference material of the partial amendment of Fire Service Act, published by Fire and Disaster Management Agency of Japan. 2 It states that the prefectural government should formulate and announce a list of hospitals and criteria for choosing an adequate hospital from the list. The Tokyo Metropolitan Government has already published a list of hospitals that can adequately treat acute stroke on the Internet. 3 The details of the development of 5
4 Aruga T Judgment of the grade of severity by observation of the patient (observation/judgment) NO Severe or worse? YES Criteria for accreditation of hospitals for acute stroke Condition 1. Experienced physicians and paramedical staff Not t-pa ready Required t-pa ready Required for the t-pa ready approval 2. CT, MRI, and clinical tests Neurological findings (including CPSS) 3. Acute-phase rehabilitation, with physical/ occupational therapist(s) 4. Neurosurgeon(s) 5. Physician(s) who have taken the t-pa therapy therapy course approved by Japan Stroke Society 6. t-pa therapy within 1 hour of arrival hours of observation after t-pa therapy NO Possibility of stroke? YES NO Within 24 hours after onset? YES Secondary medical institution (hospital) Group-B hospital for acute stroke (not t-pa ready) Group-A hospital for acute stroke (t-pa ready) Emergency critical care center, etc. Fig. 3 Protocol for selection of a receiving hospital for an acute stroke patient (Tokyo, Japan) an emergency medical liaison system for acute stroke care in Tokyo are described below. In short, as of February 1, 2009, which was just before the full-scale operation of the liaison system started, there were a total of 162 institutions that can deal with acute stroke, and intravenous tissue plasminogen activator (t-pa) therapy was available in 104 of them. Since the beginning of full-scale operation of the system in March 2009, the numbers of such institutions have been increasing gradually. Below the formulation of the medical liaison system in Tokyo will be described, including discussions from the viewpoint of healthcare providers as well as those responsible for the transport of patients. Tokyo Stroke Care Liaison Council In Tokyo, Tokyo Stroke Care Liaison Council, comprised of Tokyo Medical Association, acute care hospitals, members of the fire authorities, and specialists in stroke and emergency medicine, was established, with Medical Policy Section of Tokyo* serving as the secretariat. The council spent a full year discussing the desirable functions of hospitals that deal with acute stroke and the necessary criteria for accrediting such hospitals. As the designated Chair of Council, I myself participated in the various discussions on wide range of topics. The first issue we discussed was to understand the available medical resources (i.e., how many hospitals could handle the acute phase of stroke, what proportion of such institutions 6
5 AN EMERGENCY MEDICAL LIAISON SYSTEM FOR ACUTE STROKE CARE IN JAPAN: AN EXAMPLE OF THE TOKYO METROPOLITAN AREA could offer surgery or administer t-pa therapy, etc.) and to examine their sufficiency. While attempting to grasp the available resources with the cooperation from Tokyo Medical Association and Tokyo Metropolitan Hospitals Association, our council defined the criteria required for acute stroke-ready hospitals and additional criteria for t-pa therapy-ready hospitals (Table 1). There are more than 100 institutions that satisfy both criteria (t-pa ready), while about 60 met the acute stroke criteria only. As mentioned previously, the name of these institutions are published by Tokyo Metropolitan Government. 3 Committee for Emergency Care Standards of Tokyo MC Council Discussions from the side of Tokyo emergency services were as follows. The medical districts of Tokyo consist of 12 secondary medical districts and island regions. There are 6 fire departments serving as headquarters in total; Tokyo Fire Department, Inagi Fire Department, Higashikurume Fire Department, and 3 departments in each island of the Oshima, Hachijo, and Miyake. Tokyo MC Council unites these 6 fire headquarters, in addition to the Medical Policy Section of Tokyo,* Tokyo Medical Association, and emergency medicine specialists, to cover the entire prefecture. Tokyo Fire Department takes the role of the secretariat of Tokyo MC Council. Tokyo MC Council has four subordinate committees, such as Committee for Post-hoc Verification and Committee for Emergency Care Standards. For the duties described in Items 2 and 3 of Fig. 2, Committee for Emergency Care Standards is in charge. As the chair of Committee for Emergency Care Standards of Tokyo MC Council, I led the movements of developing the rules for identifying stroke patients, determining appropriate emergency care, and selecting the receiving hospitals to transport emergency patients, as well as obtaining approval from the parent organization, Tokyo MC Council. Tokyo Fire Department already had emergency service activity standards, which the other 5 fire departments were observing in principle. Therefore, a part of these standards corresponding to stroke care were checked with the prehospital stroke life support (PSLS) criteria 4 that provides standards for observation and treatment of stroke in prehospital emergency care. Although there were basically no excess or deficiency in observation items, the criteria of the Cincinnati prehospital stroke scale (CPSS), which suspects stroke whenever any facial paralysis, upper limb paralysis, or speech impairment is present, were added to the protocol with emphasis (Fig. 3). Regardless of the possibility of stroke, a conventional rule for patients with severe or worse is to transport to an emergency critical care center (, which are approved by Ministry of Health, Labour and Welfare of Japan, as tertiary healthcare facility equipped to provide advanced acute care). In terms of the level of consciousness, a score of 100 to 300 in Japan Coma Scale (JSC; system) is regarded as a severe case, and the transport to an emergency critical care center is deemed necessary. Furthermore, most stoke patients within 1 day of onset were transported to hospitals where emergency neurosurgery was available. During the course of our discussions, there was an opinion that patients with strokeinduced coma be included in the transport rule of stroke patients. Some also insisted that patients within a few hours of onset be transported to hospitals where t-pa therapy is available, considering that t-pa must be administered within such limited time frame. However, t-pa therapy is available at all emergency critical care centers, and they are equivalent to group-a hospitals for acute stroke in Fig. 3. In addition, emergency crews may be able to determine a case of stroke but not a cerebral infarction. Figure 3 illustrates the finalized protocol for emergency crews to select a receiving hospital for an acute stroke patient, which Tokyo MC Council has approved. Emergency crews are provided with roster sheets of Group-A (t-pa ready) and Group-B (not t-pa ready) hospitals for acute stroke (Fig. 3), as prepared by Tokyo Stroke Care Liaison Council. Since March 2009, patients who are suspected of stroke are being transported to a hospital based on this protocol (Fig. 3). 5 Although some local cities are progressive and have already addressed an emergency medical liaison system for acute stroke care, medical liaison is reported to be hardly in place in fire departments with smaller jurisdictional population. 6 This example of Tokyo represents rulemaking in a large city with poor interpersonal relationships, and in a sense reflects a situation where a simple function or component itself is being built. 7
6 Aruga T Future Problems Excess or deficiency of stroke-ready hospitals In comparison with provincial cities, Tokyo is a large city with a large population, and its emergency services operate across the boundaries of wards, municipalities, or secondary medical districts. Therefore, it is necessary to consider the entire Tokyo area (excluding the island regions) as a single district when transporting patients. If we are to assume that 100 Group-A hospitals for acute stroke are to respond equally for the 30,000 acute stroke patients that are estimated to occur in a year for the entire Tokyo, on average a given hospital would be accepting 0.8 patient per day. However, the geographical distribution of acute care-ready hospitals is not even, and the population distribution is not homogeneous either. Therefore, patients will not likely be evenly assigned among hospitals. For example, the northern portion of North Tama Medical District is rich in rehabilitation hospitals but has insufficient medical resources for acute care despite its large population. For this reason, some advocated integrating northern, western, and southern portions of North Tama into one medical district (, as they used to exist formally as one North Tama County ) as more rational strategy. For now, there has been no reported case of unusual delay in selecting a receiving hospital for a stroke patient from the fire authorities. However, we should discuss further from the statistical aspect in the future. Medical liaison for acute stroke care and subsequent various issues As early rehabilitation training at bedside is generally required in acute care hospitals, rehabilitation activities in stroke patients are extremely important. Discussing emergency medicine requires attention to the follow-ups for the accepted patients. In other words, if patients are not properly transferred to rehabilitation facilities (wards or hospitals) for convalescence, patients become stagnated in acute care facilities which in turn mean that patients in need of emergency transport may not be properly accepted because all beds are full. From the viewpoint of acute care institutions, there are two types of medical liaison in nature; the forward type, which connects with the emergency medical services, and the backward type, which connects to rehabilitation facilities. However, patients then must flow from rehabilitation facilities to the next level of recuperation. There, regardless of location at his/her own home or at an institution, a patient in the maintenance phase requires certain kinds of support for daily activities. Naturally, such support also involves prevention of recurrent stroke. In other words, when we consider a medical liaison system for the acute phase, we must also refer to a comprehensive and continuous recuperation environment for patients at the community level. 7 As mentioned in the example of old North Tama County, we must be aware that such viewpoint plays important role in a medical liaison system. Case assessment by emergency crews and definitive diagnosis by physicians According to the data accumulated by the emergency medical services, 6 stroke patients accounts for 9.8% of all transport of acute cases. When the jurisdictional population size per fire headquarter is considered, this proportion shows a declining tendency as the population increases; from 14.6% (for headquarters with jurisdictional population of 50,000), to 13.6% (100,000), 10.6% (300,000), and 7.8% (300,000). Aside from the implications of these figures, it is, in fact, unclear whether these patients who were assessed as stroke were definitively diagnosed as one eventually. Emergency patients initially transported as stroke patients are often found to have diabetes or chronic subdural hematoma, or conversely, received patients who were not suspected of stroke may later be diagnosed with stroke. The survey conducted in the Nagasaki area (Nagasaki Prefecture) is well known as an example that matched emergency transport cases and definitive diagnoses. 8 However, the report provided no mention of the relationship between the assessment by emergency crews and the subsequent definitive diagnosis by physicians. Recently in Osaka Prefecture, the results of such matching between Kishiwada City Fire Department and hospitals within its jurisdiction have been reported, 9 which possibly marks the first step towards improving in the quality of observation/assessment of stroke made by emergency crews. The primary objective of MC Council is assurance and improvement of the quality of emergency services. In the future, it would be 8
7 AN EMERGENCY MEDICAL LIAISON SYSTEM FOR ACUTE STROKE CARE IN JAPAN: AN EXAMPLE OF THE TOKYO METROPOLITAN AREA desirable to sort the data based on the assessment of emergency crews as either stroke or not and investigate their relationship with the definitive diagnosis, in order to build the process of learning for emergency services through checking their assessment with the definitive diagnosis. Conclusion This paper discussed the issue of emergency medical liaison for acute stroke care in Japan, focusing on the efforts made in Tokyo. These efforts, which preceded the recent partial amendment of Fire Service Act, can be regarded as a good tangible form of the amendment s main purport. Considering a desirable system of emergency medical liaison for acute stroke care requires discussions of comprehensive and continuous recuperation environment for patients in the community with the flow of patients in mind. From this aspect, and to improve the quality of emergency transport of stroke patients, other related issues were also examined. * The official name is; Medical Policy Section, Medical Policy Division, Bureau of Social Welfare and Public Health, Tokyo Metropolitan Government. References 1. Yokota J. Report from the Medical Control Working Group: Fiscal 2008 Report of the Investigative Commission for Emergency Services Improvement Promotion. Fire and Disaster Management Agency; p (in Japanese) 2. Fire and Disaster Management Agency. Fiscal 2008 Report of the Investigative Commission for Emergency Services Improvement Promotion Mar. Reference Material 2. (in Japanese) 3. Tokyo Metropolitan Medical Institution Information Service Himawari (Sunflower). qq13enmnlt.asp (Accessed Aug 2010). 4. Japanese Society for Emergency Medicine (sup.). PSLS Course Guidebook. Tokyo: Herusu Shuppan, Co. Inc.; (in Japanese) 5. Sakurai Y. Toward the formulation of the medical liaison system for stroke in Tokyo. Liaison Committee of Directors in Charge of Regional Cooperation at Tokyo Medical Association; 2009 Jan 29. (in Japanese) 6. Miyamatsu N, Okumura T, Aruga T, et al. Survey on the emergency transport system for the early phase of stroke Ministry of Health, Labour and Welfare Grant-in-Aid for Scientific Research, Lifestyle Related Diseases (Including Cardiovascular Disease) Joint Research Project Survey of the actual situation of the emergency transport of patients with hyper-acute cerebral infarction and the system of acceptance by acute care hospitals (Principal Investigator: Kimura K), Fiscal 2008 Report Mar. p (in Japanese) 7. Kurihara M. Desirable form of the community emergency medical system. Journal of Japanese Society for Emergency Medicine. 2007;10: (in Japanese) 8. Liaison Committee of Nagasaki Clinical Emergency Medicine in Nagasaki City White Paper on Nagasaki Emergency Medicine: Survey on the Status of Emergency Medical Services in Nagasaki Area (from April 2007 to March 2008). Nagasaki City: Kyushu-Insatsu; 2009 Mar. (in Japanese) 9. Yukimoto T, Horizoe K, Fujiki T, et al. Adequacy of the evaluation of stroke patients by emergency crews (, presented at the 12th Congress of the Japanese Society for Emergency Medicine; 2009 Jun; Osaka). Journal of Japanese Society for Emergency Medicine. 2009;12:191. (in Japanese) 9
Trauma Service Area - B (BRAC) Regional Stroke Plan
Trauma Service Area - B (BRAC) Regional Stroke Plan Trauma Service Area- B (BRAC) P.O. Box 53597 Lubbock, TX 79453 806.791.2582 (office) BRAC serves the counties of Bailey, Borden, Castro, Cochran, Cottle,
More informationOverview of Tokyo Metropolitan Hospitals
Overview of Tokyo Metropolitan Hospitals History of Tokyo Metropolitan Hospitals The history of Tokyo metropolitan hospitals dates back to 1879, when facilities for mental illness and cholera and other
More informationPerspectives of Future Healthcare IT
KUZUNO Hiroshi, KANAZAWA Masaki, IINO Akemi, ANDOH Masataka, TOKUSHIMA Daisuke Abstract In Japan, the increase in the rate of ageing in the population has made the optimization of medical expenditure more
More informationHFAP Stroke Survey. Overview of the Survey Process 8/17/2011
HFAP Stroke Survey Surveyors Viewpoint Bernard C. McDonnell, D.O. Stroke Center Accreditation from the Surveyors Viewpoint 01.00.01 Primary stroke Center Facility Commitment. The leadership of the facility
More informationFIRE AND DISASTER MANAGEMENT ORGANIZATION ACT
FIRE AND DISASTER MANAGEMENT ORGANIZATION ACT (LAW NO. 226, DEC. 23, 1947) Amendments (1) Law No. 187, Jul.24, 1948 (25) Law No.83, Dec.10, 1983 (2) Law No.193, Jun.4, 1949 (26) Law No.69, Jun.21, 1985
More informationActivities of the Japan Medical Association Team in Response to the Great East Japan Earthquake
Conferences and Lectures Special Feature: JMA Symposium on Health Policy Disaster Medicine and Medical Associations Activities of the Japan Medical Association Team in Response to the Great East Japan
More informationMinisterial Ordinance on Good Laboratory Practice for Nonclinical Safety Studies of Drugs
Provisional Translation (as of August 2012) Ministerial Ordinance on Good Laboratory Practice for Nonclinical Safety Studies of Drugs Ordinance of the Ministry of Health and Welfare No.21 of March 26,
More informationWINNIPEG SCHOOL DIVISION CONCUSSION PROTOCOL
Concussion Protocol SUMMARY The following is a summary of the. 1) All students attending a school and their parents are encouraged to review the Canadian Guideline on Concussion in Sport Pre-season Concussion
More informationDetailed planning for secure health care delivery
Detailed planning for secure health care delivery Country: Japan Partner Institute: Kinugasa Research Institute, Ritsumeikan University, Kyoto Survey no: (9)2007 Author(s): Matsuda, Ryozo Health Policy
More informationRegional Perinatal Medical Care Systems: Efforts of Kanagawa Prefecture, Japan
Conferences and Lectures Regional Perinatal Medical Care Systems: Efforts of Kanagawa Prefecture, Japan JMAJ 53(2): 81 85, 2010 Hiroshi ISHIKAWA* 1 Introduction Pregnancy and childbirth always carry potential
More informationFrameworks for Responses to Armed Attack Situations
Section 2 Frameworks for Responses to Armed Attack Situations It is of utmost importance for the national government to establish a national response framework as a basis for an SDF operational structure
More informationSection 3. Organization of the MOD/SDF
Part II The Basics of Japan s Defense Policy Section 3. Organization of the MOD/SDF The Self-Defense Forces (SDF), the core of Japan s defense capability, is a specialist organization that plays the most
More informationUnderstanding the Implications of Total Cost of Care in the Maryland Market
Understanding the Implications of Total Cost of Care in the Maryland Market January 29, 2016 Joshua Campbell Director KPMG LLP Matthew Beitman Sr. Associate KPMG LLP The concept of total cost of care is
More informationCore Elements of Delivery of Stroke Prevention Services
Core Elements of Delivery of A critical component of secondary stroke prevention is access to specialized stroke prevention services (SPS), ideally provided by dedicated stroke prevention clinics. Stroke
More informationJICA Thematic Guidelines on Nursing Education (Overview)
JICA Thematic Guidelines on Nursing Education (Overview) November 2005 Japan International Cooperation Agency Overview 1. Overview of nursing education 1-1 Present situation of the nursing field and nursing
More informationEvaluation of Telestroke Services
Evaluation of Telestroke Services 2013 Telestroke Summit Heart and Stroke Foundation of New Brunswick and the Canadian Stroke Network Dr. Patrice Lindsay Director Best Practices and Performance, Stroke
More informationEvaluation and Licensing Division, Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare
Notification number: 0427-1 April 27, 2015 To: Prefectural Health Department (Bureau) Evaluation and Licensing Division, Pharmaceutical and Food Safety Bureau, Ministry of Health, Labour and Welfare Notification
More informationGeneral Authority for Health Services for the Emirate of Abu Dhabi
Subject: Hospital Referral Ref: 001/07 1 16 PURPOSE To standardize patient referrals and transfers among Abu Dhabi Hospitals POLICY STATEMENT 1. Transferring patients between hospitals should be based
More informationPART ENVIRONMENTAL IMPACT STATEMENT
Page 1 of 12 PART 1502--ENVIRONMENTAL IMPACT STATEMENT Sec. 1502.1 Purpose. 1502.2 Implementation. 1502.3 Statutory requirements for statements. 1502.4 Major Federal actions requiring the preparation of
More informationAct on Social Welfare for the Elderly
Act on Social Welfare for the Elderly (Act No. 133 of July 11, 1963) Chapter I General Provisions (Article 1 to Article 10-2) Chapter II Welfare Measures (Article 10-3 to Article 13-2) Chapter III Services
More informationGrey Bruce Health Services. Executive Compensation Framework. January 2018
Grey Bruce Health Services Executive Compensation Framework January 2018 2 Grey Bruce Health Service (GBHS) is in the process of establishing an Executive Compensation Framework, a new requirement of the
More informationStroke System-of- Care Plan. Mississippi State Department of Health
Stroke System-of- Care Plan Mississippi State Department of Health Bureau of Acute Care Systems MSDH Board of Health Approved: October 14, 2015 Revised July 6, 2015 Stroke System-of-Care Plan Table of
More informationSpecialised Services Commissioning Policy: CP160 Specialised Paediatric Neurological Rehabilitation
Specialised Services Commissioning Policy: CP160 Specialised Paediatric Neurological Rehabilitation April 2018 Version 4.0 Document information Document purpose Document name Author Policy Specialised
More informationAttachment B ORDINANCE NO. 14-
ORDINANCE NO. 14- AN ORDINANCE OF THE COUNTY OF ORANGE, CALIFORNIA AMENDING SECTIONS 4-9-1 THROUGH 4-11-17 OF THE CODIFIED ORDINANCES OF THE COUNTY OF ORANGE REGARDING AMBULANCE SERVICE The Board of Supervisors
More information(5) Securing Health and Medical Care Service Systems
Breakdown (5) Securing Health and Medical Care Service Systems The TMG has been striving in the improvement of emergency medical care and in-home medical care and establishment of local medical care system
More informationWinning in Japan. Danny Risberg, General Manager Market Japan, Philips Healthcare
Winning in Japan Danny Risberg, General Manager Market Japan, Philips Healthcare Key takeaways Hospital to Home solution is a key driver for growth in Japan Hyper-aging society Expensive hospital system
More informationElement(s) of Performance for DSPR.1
Prepublication Issued Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationCare Worker in Technical Intern Training Program. Social Welfare and War Victims' Relief Bureau Ministry of Health, Labour and Welfare
Care Worker in Technical Intern Training Program Social Welfare and War Victims' Relief Bureau Ministry of Health, Labour and Welfare Basic concept Addition of the Care Worker in job category of technical
More informationGrey Bruce Health Services (GBHS) Executive Compensation Framework. February Final Copy
Grey Bruce Health Services (GBHS) Executive Compensation Framework February 2018 Final Copy Grey Bruce Health Service has established an Executive Compensation Framework, a new requirement of the provincial
More informationMid-term Targets of the Pharmaceuticals and Medical Devices Agency (PMDA) *(Provisional Translation)
Mid-term Targets of the Pharmaceuticals and Medical Devices Agency (PMDA) *(Provisional Translation) * This translation of the original Japanese text is for information purposes only (in the event of inconsistency,
More informationALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-5 PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER TABLE OF CONTENTS
Medicaid Chapter 560-X-5 ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-5 PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER TABLE OF CONTENTS 560-X-5-.01 560-X-5-.02 560-X-5-.03 560-X-5-.04
More informationInvestigation of Changes in Library Usage after the Introduction of Outsourcing in Japan
Investigation of Changes in Library Usage after the Introduction of Outsourcing in Japan Yuhiro Mizunuma 1, Keita Tsuji 2 1 Graduate School of Library, Information and Media Studies, University of Tsukuba,
More informationSeven Day Services Clinical Standards September 2017
Seven Day Services Clinical Standards September 2017 11 September 2017 Gateway reference: 06408 Patient Experience 1. Patients, and where appropriate families and carers, must be actively involved in shared
More informationCommissioning Policy
Commissioning Policy Consultant to Consultant Referrals Version 6.0 December 2017 Name of Responsible Board / Committee for Ratification: North Staffordshire CCG Stoke on Trent CCG Date Issued: November
More information# December 29, 2000
#00-53-3 December 29, 2000 Minnesota Department of Human Services 444 Lafayette Rd. St. Paul, MN 55155 OF INTEREST TO! County Social Service Directors/Supervisors! County Designated LMHA for PASRR! County
More informationDefinition of expanded role; limitations; restrictions. (a) Each advanced registered nurse practitioner (ARNP), as defined by K.S.A.
60-11-101. Definition of expanded role; limitations; restrictions. (a) Each advanced registered nurse practitioner (ARNP), as defined by K.S.A. 65-1113 and amendments thereto, shall function in an expanded
More informationStroke and TIA Service and Quality Core Standards 2016
Stroke and TIA Service and Quality Core Standards 2016 Authors: Jackie Hudleston and Dr David Hargroves with Stroke Clinical Advisory Group Email: england.secn@nhs.net www.secn.nhs.uk Table of Contents
More informationExecutive Summary. This Project
Executive Summary The Health Care Financing Administration (HCFA) has had a long-term commitment to work towards implementation of a per-episode prospective payment approach for Medicare home health services,
More informationDamages and Response to Great East Japan Earthquake. Guidance of medical service division, Health policy bureau, MHLW, JAPAN
Damages and Response to Great East Japan Earthquake Guidance of medical service division, Health policy bureau, MHLW, JAPAN 1 content Disaster Base Hospital JAPAN Disaster Medical Assistance Team (DMAT)
More informationSELKIRK MENTAL HEALTH CENTRE ACQUIRED BRAIN INJURY PROGRAM MODEL OCTOBER Striving for Excellence in Rehabilitation, Recovery, and Reintegration.
SELKIRK MENTAL HEALTH CENTRE ACQUIRED BRAIN INJURY PROGRAM MODEL OCTOBER 2008 Striving for Excellence in Rehabilitation, Recovery, and Reintegration. SELKIRK MENTAL HEALTH CENTRE ACQUIRED BRAIN INJURY
More informationCh. 117 EMERGENCY SERVICES 28 CHAPTER 117. EMERGENCY SERVICES GENERAL PROVISIONS EMERGENCY SERVICES PLANNING ORGANIZATIONS
Ch. 117 EMERGENCY SERVICES 28 CHAPTER 117. EMERGENCY SERVICES Sec. 117.1. Provision of services. GENERAL PROVISIONS 117.11. Emergency services plan. 117.12. Procedures. 117.13. Scope of services. 117.14.
More informationCommission on Accreditation of Allied Health Education Programs
Commission on Accreditation of Allied Health Education Programs Standards and Guidelines for Cardiovascular Technology Educational Programs Essentials/Standards initially adopted 1985; revised in 2003
More informationJob Title. Position Description. Functional Relationships with : Internal Service users, health care team members, Quality Manager.
Date: January 2014 Job Title : Registered Nurse. Department : Auckland Regional Forensic Psychiatry Services. Location : Auckland Regional Forensic Psychiatry Services. Reporting To : Associate Service
More informationNeurocritical Care Fellowship Program Requirements
Neurocritical Care Fellowship Program Requirements I. Introduction A. Definition The medical subspecialty of Neurocritical Care is devoted to the comprehensive, multisystem care of the critically-ill neurological
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationSection 2 Frameworks for Responses to Armed Attack Situations
Section 2 Frameworks for Responses to Armed Attack Situations It is of utmost importance for the national government to establish a national response framework as a basis for SDF operational structure
More informationOrganizational Communication in Telework: Towards Knowledge Management
Association for Information Systems AIS Electronic Library (AISeL) PACIS 2001 Proceedings Pacific Asia Conference on Information Systems (PACIS) December 2001 Organizational Communication in Telework:
More informationIMCI at the Referral Level: Hospital IMCI
Integrated Management of Childhood Illness (IMCI) Implementation in the Western Pacific Region IMCI at the Referral Level: Hospital IMCI 6 IMCI at the Referral Level: Hospital IMCI Hospital referral care:
More informationShoulder program of care. reference guide OCTOBER 2012
Shoulder program PROGRAM OF CARE of care reference guide OCTOBER 2012 Reference guide Acknowledgements The WSIB acknowledges the significant contributions of the following regulatory colleges, regulated
More informationMINISTRY OF HEALTH AND LONG-TERM CARE. Summary of Transfer Payments for the Operation of Public Hospitals. Type of Funding
MINISTRY OF HEALTH AND LONG-TERM CARE 3.09 Institutional Health Program Transfer Payments to Public Hospitals The Public Hospitals Act provides the legislative authority to regulate and fund the operations
More informationMedical Safety Support Center, Medical safety, Complaint, Hospital violence, Lawsuit
Research and Reviews Status of Medical Disputes in Hospitals in Tokyo Prefecture, Japan, and the Role of Medical Safety Support Centers in Resolving Disputes: Primary survey JMAJ 53(4): 209 217, 2010 Itaru
More informationSafety, Industrial Hygiene
Management Fundamentals Safety, Industrial Hygiene Mission Safety First, Always At Bridgestone, we make safety a business value. Creating a safe working place for all is everyone s responsibility. Refined
More informationFamily Practice Clinic
Family Practice Clinic FNP Job Description (Hospital Privileges) General: The Family Nurse Practitioner (FNP) assesses, plans and provides comprehensive patient care independently or in autonomous collaboration
More informationDeveloping Plans for the Better Care Fund
Annex to the NHS England Planning Guidance Developing Plans for the Better Care Fund (formerly the Integration Transformation Fund) What is the Better Care Fund? 1. The Better Care Fund (previously referred
More informationGuidelines for Conflict of Interest Issues Related to Clinical Studies in Artificial Organs. Attached Documents
Guidelines for Conflict of Interest Issues Related to Clinical Studies in Artificial Organs Attached Documents 1. Guidelines for Conflict of Interest Issues Related to Clinical Studies in Artificial Organs
More informationCounty of Santa Clara Emergency Medical Services Agency
County of Santa Clara Emergency Medical Services Agency Public Health Department 645 South Bascom Avenue San Jose, California 95128 (Tel) 408.885.4250 (Fax) 408.885.3538 August 8, 2007 To: From: Copy:
More informationBasic Teaching Physician Presence and Documentation
Basic Teaching Physician Presence and Documentation Welcome to the Children s University Medical Group (CUMG) training on the Teaching Physician Presence and Documentation. The goal of this module is to
More information2019 Medicare Advantage and Part D Advance Notice Parts I and II and Draft Call Letter: Ensuring Access to Medical Rehabilitation Services
DRAFT March 5, 2018 VIA ELECTRONIC MAIL Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Re:
More informationBY-LAW #3 (Under Section 40(2) of The Medical Act)
1000 1661 PORTAGE AVENUE, WINNIPEG, MANITOBA R3J 3T7 TEL: (204) 774-4344 FAX: (204) 774-0750 BY-LAW #3 (Under Section 40(2) of The Medical Act) ACCREDITED FACILITIES (Enacted by the Councillors of the
More informationMedicare Home Health Prospective Payment System (HHPPS) Calendar Year (CY) 2013 Final Rule
Last updated 11/13/12 Contact: Advocacy@apta.org Medicare Home Health Prospective Payment System (HHPPS) Calendar Year (CY) 2013 Final Rule Introduction COMPREHENSIVE SUMMARY On November 2, 2012, the Centers
More information2009 Final Medicare Physician Fee Schedule (CMS-1403-FC) Rule Summary
2009 Final Medicare Physician Fee Schedule (CMS-1403-FC) Rule Summary The 2009 Final Medicare Physician Fee Schedule will be published in the Federal Register on November 19, 2008. A display copy of this
More informationANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010
ANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010 Objective Action Desired Output / Monitor and manage all those at risk of stroke and, refer as appropriate to smoking cessation services,
More informationLuton Borough Council: Reducing DTOC rates attributable to Social Care
Briefing 17/20 May 2017 Insights into Social Care Practice Insights is a series of case studies, intended to promote and share the good practice among APSE member authorities in delivering adult social
More informationKingston Health Sciences Centre EXECUTIVE COMPENSATION PROGRAM
Kingston Health Sciences Centre EXECUTIVE COMPENSATION PROGRAM Background In 2010, the Province of Ontario legislated a two-year compensation freeze for all non-unionized employees in the Broader Public
More informationJurnal Ners Vol 3 No 2 Oktober 2008-Maret 2009
Jurnal Ners Vol 3 No Oktober 008-Maret 009 A COMPARATIVE STUDY OF NURSING EDUCATIONAL SYSTEM IN INDONESIA AND JAPAN Susiana Nugraha 1, Mika Tanaka, Ferry Efendi 3 1 Member of Indonesian National Nursing
More informationMacquarie University - Doctor of Physiotherapy Program Admission, Program and Inherent Requirements
Macquarie University - Program Admission, Program and Inherent Requirements Overall Definition Inherent requirements are the essential activities, capacities and academic requirements that are necessary
More informationCHAPTER 117. EMERGENCY SERVICES GENERAL PROVISIONS EMERGENCY SERVICES PLANNING ORGANIZATIONS
Ch. 117 EMERGENCY SERVICES 28 CHAPTER 117. EMERGENCY SERVICES Sec. 117.1. Provision of services. GENERAL PROVISIONS 117.11. Emergency services plan. 117.12. Procedures. 117.13. Scope of services. 117.14.
More informationMedical Staff Rules & Regulations Last Updated: October University Hospital Medical Staff. Rules & Regulations
University Hospital Medical Staff Rules & Regulations 1 UNIVERSITY HOSPITAL MEDICAL STAFF RULES AND REGULATIONS The Medical Staff shall adopt Rules and Regulations as may be necessary to implement the
More informationReference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria.
InterQual Level of Care Criteria Rehabilitation Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationDEPARTMENT OF PUBLIC HEALTH
DEPARTMENT OF PUBLIC HEALTH Emergency Medical Services Agency POLICY #542.00 TITLE: PATIENT REFUSAL OF EMERGENCY MEDICAL SERVICE, REFUSAL AGAINST MEDICAL ADVICE (AMA) & QUALIFY FOR RELEASE AT SCENE (RAS)
More informationALLIED HEALTH VACANCY REPORT
May 2005 ALLIED HEALTH VACANCY REPORT by Rebecca Livengood, MSPH; Erin Fraher, MPP; and Susan Dyson, MHA INTRODUCTION One of the primary goals of the Council for Allied Health in North Carolina is to ensure
More informationMaking the Most of the Ambulance Service
Making the Most of the Ambulance Service ~ When do we need an ambulance? ~ In recent years, we have seen an increase in both the number of times ambulances get called out, and
More informationPhysicians Who Care for People with MS
Physicians Who Care for People with MS Neurologists: Specialize in the diagnosis and treatment of conditions related to the nervous system including the brain, spinal cord, and nerves. Many neurologists
More informationPOLICIES AND PROCEDURES
POLICIES AND PROCEDURES POLICY: 535.10 TITLE: EFFECTIVE: 4/13/17 REVIEW: 4/2022 SUPERCEDES: APPROVAL SIGNATURES ON FILE IN EMS OFFICE PAGE: 1 of 14 I. AUTHORITY Division 2.5, California Health and Safety
More informationREVIEW AGENDA AND LOGISTICS
REVIEW AGENDA AND LOGISTICS The purpose of the American College of Surgeons Verification, Review, & Consultation (VRC) Program is to verify a hospital s compliance with the ACS standards for a trauma center.
More informationAppeal Process Information
First-Level Appeals Appeal Process Information Regulation 7 AAC 105.270 stipulates the length of time a provider has to submit a first-level appeal. Most firstlevel appeals must be filed within 180 days
More informationAchieving the objectives and carrying out the key responsibilities and duties as described.
TAIRAWHITI DISTRICT HEALTH POSITION DESCRIPTION POSITION: RESPONSIBLE TO: RESPONSIBLE FOR: Obstetrician & Gynaecologist Clinical Director and Clinical Care Manager Achieving the objectives and carrying
More informationRECOMMENDATION STATUS OVERVIEW
Chapter 2 Section 2.01 Community Care Access Centres Financial Operations and Service Delivery Follow-Up on September 2015 Special Report RECOMMENDATION STATUS OVERVIEW # of Status of Actions Recommended
More informationExhibit A Covered Employee Notification of Rights Materials Regarding Pacific Compensation Insurance Company PCIC on the Job MPN
Exhibit A Covered Employee Notification of Rights Materials Regarding Pacific Compensation Insurance Company PCIC on the Job MPN This pamphlet contains important information about your medical care in
More informationProposed Requirements for Comprehensive Stroke Center
Proposed Requirements for Comprehensive Stroke Center Please Note: The current requirements for Disease-Specific Care Advanced Certification Program for Primary Stroke are included in this document. Proposed
More informationRegistered Nurse. Position Description
Date: March 2016 Job Title : Level 2 Competent Registered Nurse Department : Auckland Regional Forensic Psychiatry Services Location : Auckland Regional Forensic Psychiatry Services Reporting To : Unit
More informationNURSE PRACTITIONER STANDARDS FOR PRACTICE
NURSE PRACTITIONER STANDARDS FOR PRACTICE February 2012 Acknowledgement The College of Registered Nurses of Prince Edward Island gratefully acknowledges permission granted by the Nurses Association of
More informationSAMPLE POLICY FOR THE REFUSAL OF CARE, TRANSPORTATION OR RECOMMENDED DESTINATION
SAMPLE POLICY FOR THE REFUSAL OF CARE, TRANSPORTATION OR RECOMMENDED DESTINATION Disclaimer: This policy is provided as a sample educational tool for ambulance services and is not intended as legal advice.
More informationAnalysis of Collaborations between Small-Medium Companies and Universities Based on Joint Research Projects
211 3rd International Conference on Information and Financial Engineering IPEDR vol.12 (211) (211) IACSIT Press, Singapore Analysis of Collaborations between Small-Medium Companies and Universities Based
More information1. Name of the Project 2. Background and Necessity of the Project
Ex-Ante Evaluation 1. Name of the Project Country: Republic of India Project: Tamil Nadu Urban Health Care Project Loan Agreement: March 31, 2016 Loan Amount: 25,537 million yen Borrower: The President
More informationReferral Guidance DIRECT REFERRAL SERVICE FOR THE ELDERLY DEAF
Referral Guidance A & E GPs are strongly requested to contact the specialty teams DIRECTLY WHEN APPROPRIATE to avoid unnecessary delays for their patients in A & E. Relevant non-urgent conditions can be
More informationCommission on Accreditation of Allied Health Education Programs
Commission on Accreditation of Allied Health Education Programs Standards and Guidelines for the Accreditation of Educational Programs in Cardiovascular Technology Essentials/Standards initially adopted
More informationLearning Experiences Descriptions
Anticoagulation Management Clinic Learning Experiences Descriptions The Anticoagulation Management rotation is an elective learning experience that focuses on the outpatient management of anticoagulation.
More informationReport on Provincial Wait Time Strategy
Hôpital régional de Sudbury Regional Hospital Report on Provincial Wait Time Strategy May 2007 Provincial Wait-time Strategy Announced by Minister of Health in November 2004 Focus is to increase access
More informationREVIEW OF PROVIDENCE ALASKA MEDICAL CENTER CERTIFICATE OF NEED APPLICATION FOR CONSTRUCTION OF AN ELECTROPHYSIOLOGY LABORATORY
REVIEW OF PROVIDENCE ALASKA MEDICAL CENTER CERTIFICATE OF NEED APPLICATION FOR CONSTRUCTION OF AN ELECTROPHYSIOLOGY LABORATORY September 14, 2009 Sean Parnell Governor William H. Hogan Commissioner State
More informationCHAPTER 1. Introduction and background of the study
1 CHAPTER 1 Introduction and background of the study 1.1 INTRODUCTION The National Health Plan s Policy (ANC 1994b:4) addresses the restructuring of the health system in South Africa and highlighted the
More informationCourse Title FUNCTIONAL ASSESSMENT OF PATIENTS WITH CARDIOVASCULAR DISEASES
Course Title FUNCTIONAL ASSESSMENT OF PATIENTS WITH CARDIOVASCULAR DISEASES Director Judith Regensteiner, Ph.D., Professor of Medicine Director, Clinical Treadmill Laboratory, UCHSC Background & Objectives
More informationFormulation of the Guideline: Guidelines on Maintaining and Improving Health of Emergency Workers at Nuclear Facilities, etc.
Labour Standards Bureau Notification No. 0831-10 31 August 2015 To: Directors Prefectural Labour Bureaus From: Director Labour Standards Bureau Ministry of Health, Labour and Welfare (Official seal imprinted)
More informationChapter Two. Preadmission Screening and Annual Resident Review (PASARR)
Preadmission Screening and Annual Resident Review (PASARR) Introduction The information in this chapter addresses Preadmission Screening and Annual Resident Review (PASARR) requirements for applicants
More informationOn The Path to a Cure: From Diagnosis to Chronic Disease Management. Brief to the Senate Committee on Social Affairs, Science and Technology
250 Bloor Street East, Suite 1000 Toronto, Ontario M4W 3P9 Telephone: (416) 922-6065 Facsimile: (416) 922-7538 On The Path to a Cure: From Diagnosis to Chronic Disease Management Brief to the Senate Committee
More informationQ&A on the Startup Visa
Q&A on the Startup Visa 1. The Scheme of the Business Startup Program for Foreign Nationals... 1 Question 1: Who is eligible to use it?... 1 Question 2: What are the merits of this scheme? Also, what are
More informationCommunity Health Needs Assessment for Corning Hospital: Schuyler, NY and Steuben, NY:
Community Health Needs Assessment for Corning Hospital: Schuyler, NY and Steuben, NY: November 2012 Approved February 20, 2013 One Guthrie Square Sayre, PA 18840 www.guthrie.org Page 1 of 18 Table of Contents
More informationClinical Medical Policy Department Clinical Affairs Division DESCRIPTION
Inpatient Rehabilitation Facilities (IRFs) [For the list of services and procedures that need preauthorization, please refer to www.mcs.pr Go to Comunicados a Proveedores, and click Cartas Circulares.]
More informationINCLUSION CRITERIA. REMINDER: Please ensure all stroke and TIA patients admitted to hospital are designated as "Stroke Service" in Cerner.
ACUTE STROKE CLINICAL PATHWAY The clinical pathway is based on evidence informed practice and is designed to promote timely treatment, enhance quality of care, optimize patient outcomes and support effective
More informationJuly 2018 TRAUMA REGISTRY UPDATE. Excellence, Innovation, Integrity & Teamwork
Trauma Program Registrars, Trauma Program Managers/Coordinators & Trauma Performance Improvement Coordinators: Please review the below information for multiple trauma registry-related updates. If you have
More information